Mark Pellegrino, MD, Offers Insights on Motherhood and Fibromyalgia

Few physicians grasp the issues involved in fibromyalgia pregnancy. In this article Dr. Mark Pellegrino, MD, offers insights from his experience managing many FM moms (and dads). It is excerpted from his highly praised book, Fibromyalgia: Up Close and Personal.*

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Fibromyalgia affects mostly women, and many of them are first bothered by symptoms in their early reproductive years, so it is common for issues regarding pregnancy to surface.

A frequent question is whether or not a woman should consider getting pregnant if she has fibromyalgia. From a medical perspective, there is no contraindication or unusual medical risk involved with Fibromyalgia and pregnancy.

Fibromyalgia has not been shown to cause infertility or increased miscarriages.

Endometriosis frequently occurs with Fibromyalgia and may cause problems with getting pregnant.

Fibromyalgia has a hereditary component and could be passed on from parent to child, but this is not considered a dangerous medical risk or a reason to avoid pregnancy.

Another concern is whether or not the pregnancy will cause a significant flare-up for the pregnant woman, or perhaps aggravate the condition to a more severe level that persists after the pregnancy.

I have treated many women for whom pregnancy has played a major role in the onset of fibromyalgia. A number of women in my practice have indicated that they were never bothered by any symptoms before pregnancy, but since then, they have had persistent muscle pains and have been diagnosed with fibromyalgia.

Surprisingly, though, I find that more women who develop Fibromyalgia from pregnancy do so after their second pregnancy, not their first.

Another group of women have indicated that they had some pre-existing mild muscle pain, but pregnancy worsened their overall condition and led to fibromyalgia.

A few individuals traced the onset of their initial low back problems and generalized fibromyalgia to their epidural procedure during delivery.

Overall, a large number of women with pre-existing Fibromyalgia state that their condition flared up during the pregnancy. In some, the condition became worse overall, but most have said their conditions returned to their previous stable baseline after the baby was born.

Because many people seem to have problems with increased pain, does that mean the hopeful mother-to-be should be advised not to consider pregnancy because of her fibromyalgia?

Absolutely not! Despite the numerous reports, these same women will also tell you that the reward, a beautiful baby, was well worth any pain and suffering they had to endure. The benefit far outweighed the risk.

Their advice to mothers or potential mothers with Fibromyalgia is this: ‘Go ahead with it, you will be glad you did. I have no regrets and I would do the same thing all over again.” (And many do!) I think that the more sophisticated one’s knowledge, the better she will anticipate and deal with any increased pain during the whole process of making a new family member.

The woman with Fibromyalgia must consider many issues when deciding whether or not to have a child.

There may already be a strained marital relationship, which could be further strained by adding a child.

The potential mother needs to know how much help the spouse and relatives are willing to give, especially if extra help is going to be needed because of the Fibromyalgia.

Finances can be a big concern. Will the mother still be able to work and care for the baby? These issues and many more need to be carefully considered when making the decision.

Once the decision is made, the first thing that should be done, even before becoming pregnant, is to review all the medications related to Fibromyalgia.

Very few medications have been found to be completely safe during pregnancy; so as a rule of thumb, all prescription medicines should be reviewed with the primary care doctor for advice on whether or not they can be discontinued altogether.

Some medicines can be completely stopped. Others have to be weaned gradually. Remember that medicine should be completely out of her system before the woman attempts to become pregnant (about a week after stopping medicines). If one waits until the pregnancy is confirmed, the fetus will already have been exposed to the medicine for a month.

Vitamins and nutritional supplements also need to be reviewed with the doctor prior to actual pregnancy. Don’t just stop medicines, as some may need to be gradually weaned away from. Check with your doctor first.

Fibromyalgia dads should review their medications as well prior to actual attempts to impregnate their partners. However, sperm cells are well protected from medication side effects, and the chance of causing a defective sperm that will affect the fetus at the time of conception is very remote.

If medications were a crucial part of the overall pain management, there may be some increased pain once the body realizes the medicines are no longer in the system. However, there is also a readjustment phenomenon. The pain settles down again after it rebounded upward, and levels off to a more stable baseline, even though the baseline may be a little higher than the one achieved with medication.

This is the time to take advantage of more natural measures to control pain, such as using moist heating pads, hot baths, ice packs, massage, or trying to get pregnant! Certain over-the-counter pain medications may be allowed during pregnancy. Check with your primary care physician.

A hopeful mother-to-be can take several measures to decrease the risk of Fibromyalgia flare-up, whether or not medications were being used.

Here are a few tips.

1. Exercise. Stay with a regular exercise program that includes stretching and conditioning exercises, with emphasis on the back. This is always easier said than done, but hopefully the mother-to-be will already be performing a regular exercise program. This program does not have to be time-consuming. Our studies have shown that 20 minutes of exercise 3 times a week will significantly improve overall conditioning and strength. Stretching exercises should be done daily, however, and the trick is to integrate an overall program into your lifestyle and then continue even after the baby is born.

2. No smoking or exposure to secondhand smoke. Nicotine decreases the blood flow to the muscles by constricting the arteries, which decreases the oxygen and increases the pain in the muscles. Cigarette smoke can also be harmful to the fetus. Frequent coughing can strain the back and cause exacerbation of the Fibromyalgia.

3. Follow fibronomics. The mother-to-be needs to perfect the techniques of proper posture and body mechanics - and fibronomics. She will really need to call upon these skills once she has the baby... Fibromyomics is defined as the art of properly manipulating your fibromyalia bodies in the environment to enable completion of an activity with minimal pain. [Dr. Pellegrino, an MD who is also a Physiatrist (a specialist in physical medicine and rehabilitation), details solutions to FM posture and movement challenges in Chapter 15 of Fibromyalgia: Up Close and Personal.]

4. Get proper rest. Proper rest resets the body’s physiologic mechanism to help ward off injury, illness, and stress, and reduces the chance of a flare-up.

5. Schedule time for yourself. The mother-to-be should try to set aside at least an hour a day for her own private time. This isthe time to relax, listen to music, read a book, work on a hobby, or enjoy recreational activities. This will help deal with physical and emotional stress.

PREGNANCY CHANGES

What happens to the body during pregnancy as it relates to Fibromyalgia? At the beginning of pregnancy, the body’s hormones are undergoing rapid changes. The changes in the blood level concentration of various hormones such as estrogen and progesterone are necessary to enable the fetus to grow in a proper well-balanced environment and to prepare the mother for the birth.

Surging hormonal changes in the first trimester can have opposite effects on the muscles of women with Fibromyalgia.

About half of my patients state that their muscles become more painful and they experience an overall aggravation of their Fibromyalgia. In addition, many types of smells and various foods are not tolerated well, especially in the morning. These symptoms lead women to describe a feeling that they have the flu.

About half of the women, however, actually feel better from a fibromyalgia standpoint during the first trimester of pregnancy. This is somewhat surprising since, normally, any type of change in the body causes increased muscle pain.

However, not all changes must be bad, since a good percentage of women actually feel better. The reason for this improvement is probably due to hormonal changes that cause positive psychological mood changes and decreased sensitivity of the muscle pain receptors. Your body physiologically tries to make you feel “happy” during pregnancy.

During the second trimester of pregnancy, the stress to the body slowly increases.

As the fetus grows, the resulting protrusion shifts the body’s center of gravity forward. In order to compensate for this shifting weight, the lumbar spine must curve backwards, and in doing so increases the swayback posture, also known as lumbar lordosis. This position creates unusual strain on the back muscles as they work harder to maintain a balanced erect posture, and the risk of back pain increases.

For every pound of extra weight in the front of the body, there are more than two pounds of extra force exerted on the low back to compensate; so there isn’t an even trade-off. The back works harder. These muscles become stressed and are more likely to cause pain and fatigue. Also, the back is more vulnerable to injury and strain. This is true for overweight people as well.

Hormonal changes during pregnancy cause the back and pelvic ligaments to soften to enable easier stretching during delivery. However, this softening alters the structural balance of the back, increases the mechanical stress, and results in more back strain.

As the pregnancy progresses, the Fibromyalgia mother-to-be becomes more at risk for increased generalized pain, especially in the low back area, and increased fatigue. It is important to continue the regular stretching and conditioning exercises during pregnancy, especially for the low back.

Toward the end of pregnancy all the muscles, especially the spinal muscles, are more strained. The physiologic weight gain during pregnancy has increased the energy demands and requirements on the muscles. The extra breast weight further destabilizes the upper spine and mid-back area and contributes to an unnatural strained positioning. The muscles are becoming overwhelmed and aren’t “happy” anymore.

The majority of Fibromyalgia women report increased muscle pain particularly in the low back toward the end of pregnancy.

By then, all of the various factors have compounded to cause increased pain. It is difficult for the new mother-to-be to find comfortable positions or control her pain.

I have had many of my patients participate in a supervised physical therapy program that includes heat and massage to the low back during the later stages of pregnancy.

Also, trigger point injections have been helpful. This technique is not contraindicated during pregnancy, but the obstetrician and the Fibromyalgia doctors need to carefully review this possible treatment method and indications for each individual patient.

Although late pregnancy may be a difficult time, it is almost the end. The mother can call upon all of her tricks and techniques to control the pain, with a little extra help from therapy or other medical treatments if needed, and hopefully keep the condition manageable.

After childbirth, additional factors can cause acute exacerbation of back pain or Fibromyalgia symptoms.

During labor and childbirth, sudden strenuous contractions pull on the back structures. If the labor is prolonged, the already vulnerable low back can sustain acute injury.

There is no evidence that natural childbirth vs. epidural vs. C-section makes any difference in terms of whether or not the woman will experience a flare-up of Fibromyalgia back pain during childbirth. There are several patients in my practice who feel that the epidural itself was the cause of the Fibromyalgia, first starting off as back pain, then generalizing.

It is theoretically possible that there could be a “trauma” associated with the epidural, particularly difficult epidurals as my patients described, to result in a post-traumatic Fibromyalgia. However, epidurals are generally safe and only rarely result in complications, and may be necessary and recommended for childbirth. I think the potential benefits of epidurals, such as decreased pain, far outweigh any potential risk concerning Fibromyalgia.

Fibromyalgia mothers become fatigued easily during labor.

However, there is no evidence of defective uterine contraction pattern unique to fibromyalgia mothers,

Nor has there been any evidence showing that Fibromyalgia mothers should have more C-sections compared to vaginal deliveries.

POST-PREGNANCY FACTORS

Back pain may develop within hours after delivery, whether it was a vaginal delivery or a C-section. The abdominal and pelvic muscles which were stretched and weakened during the pregnancy and delivery are not able to balance the spine well, and painful muscle spasms can occur. After delivery, there is decreased mobility and activity as the new mother adjusts to the post-pregnancy changes and restores the body’s energy supply. This is a risky time for flare-ups.

Back stretching and strengthening exercises should be started within a few days after delivery, with an attempt to resume the Fibromyalgia home program as quickly as possible.

Sometimes extra support is needed, such as a back brace or abdominal binder for a few weeks until the muscles can regain their strength and provide support.

Larger breasted women who are nursing should wear a supportive bra so the extra breast weight does not further de-stabilize the spinal balance and increase neck, shoulder, or back pain.

By far the biggest challenge to the new mother’s Fibromyalgia is the newest member of the family, the infant!

This lovable, irresistible little person who weights less than ten ponds manages to get in strategic locations that are most challenging to the new mother’s ability to maintain proper low back and body posture. Whether the baby is in a crib, on the floor, or nestled in a care seat, the new mother must bend, and bend frequently, to a level below her waist.

Twisting and reaching go hand-in-hand with bending, and all three of these positions are hazardous to the vulnerable back and the Fibromyalgia mother. Carrying the infant is also difficult, and the burden on the back increases as the child grows.

Both physical and emotional stress can cause a flare-up of pain. As we know, people under stress often tense their muscles, which causes spasms and pain. New mothers are certainly under a lot of stress due to the physical and emotional responsibilities of a newborn. Even though this type of stress may be considered good, the Fibromyalgia muscles do not make a distinction.

An additional imposed stress on the new mother is sleep deprivation. Lack of sleep is synonymous with being a new mother! Increased pain and fatigue result.

Mothers who breastfeed their babies are at particular risk for sleep deprivation and this is a factor to consider when deciding whether or not you want to nurse your baby.

Mothers who nurse will probably not get back on medications as quickly as mothers who choose to bottle feed.

Most of my patients choose to bottle feed, particularly after the first pregnancy, because it causes fewer sleep problems and enables the partner to be more involved in the nighttime feedings.

Postpartum depression is also common and can lead to additional poor sleep, increased fatigue, and increased pain. Fibromyalgia women don’t seem to be more prone to postpartum depression than their non-fibromyalgia counterparts, but I wouldn’t be surprised if future research shows otherwise - since people with Fibromyalgia are more prone to clinical depression.

Given all of these stresses, it is no wonder that a new mother is more vulnerable to pain. If all of these stresses overwhelm the muscles, acute flare-ups can occur.

[Dr. Pellegrino’s further advice for decreasing risk of post-partum injury or flare-up – detailed in Chapter 40 of Fibromyalgia: Up Close and Personal - includes specifics on resuming stretching and conditioning exercises, proper posture and body mechanics in lifting and carrying the infant, pain relief medications/considerations and, for working mothers, the possibility of a longer medical leave to recover.]

Note: This information has not been evaluated by the FDA. It is not meant to diagnose, prevent, treat or cure any illness, condition, or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.

I am disappointed in Dr Pellegrino's comments about both breastfeeding and post partum depression. There is excellent research that shows that breastfeeding can be protective against post partum depression and also that PPD can be prevented and treated with the use of Omega-3 fatty acids. For anyone who is interested in more information check the website "www.breastfeedingmadesimple.com"
Women who are pregnant and considering breastfeeding or who have a baby and are feeling challanged by some aspect of breastfeeding would be wise to find a more knowledgable source of practical breastfeeding information than Dr Pellegrino. A Lactation Consultant or La Leche League Leader will be able to help you find ways to provide your baby with the best form of nutrition and keep your own body health and comfortable at the same time. Many mothers with many kinds of health challanges have breastfed thier babies. Don't discard the idea of breastfeeding just becuase of Dr Pellegrino's comments, do your own research and make an informed decision about the best choice for you and your family.

I was diagnosed with fibro when I was pregnant with my first child at 29. I tried breasfeeding with my first child, and I went into flare up and excruciating pain more than what I had during the third trimester, my baby was extremely hungry and crying and this entire situation created more stress which aggrevated the fibro more to the point I couldn't hold my baby properly to feed him due to extreme muscle fatigue and pain. The nurse recommended bottle feeding, as my milk had not started production properly and I was not functioning well enough after an induced 14 hr labor. Bottle feeding proved to be easier for me as I could get more sleep and rest, having my husband help with night feeds and my baby was satiated and settled into a routine quickly. I didn't bother trying breastfeeding with my second child. Again I was able to get more sleep and rest because she fed every 3-4 hours, and slept well settling into a routine quickly. I got rid of the milk with both babies using cabbage leaves and a tight crop top (recommended to me by a midwife). It took 10 days and my breasts were back to normal. I didn't take the recommended drug by my ob, as I was worried about side effects and how it would react to the fibro- I have a lot of drug sensitivities. Both of my children put on weight very well, and most importantly, I think, I was able to bouce back more quickly by eliminating some of the factors which was aggrevating the fibro- I had a 3 hour induced labour the second time, no breast feeding, stayed in hospital for 5 days, weighed less, ate well. I have a cleaner once a week, and order all of our food to be delivered via online suppliers making me less fatigued and able to keep ontop of managing our household. The cost of the cleaner came from money I saved by buying houselhold groceries online, and not using the car or buying those extras at the shops. All of these things made it so that I could be more relaxed, less tired and not overwhelmed, and so I could make time for myself also. I had no post partum/natal depression because I was able to manage my stress levels and pain levels more effectively.

I LOVED THIS ARTICLE

Posted by: DIAMOND_567Aug 13, 2008

I HAVE BEEN A PERSON WHO HAS SUFFER WITH M.E FOR OVER 20 YEARS AND FMS/CFS FOR SO MANY YEARS I CAN'T PUT AN EXACT NUMBER ON IT. I HAVE STUDIED THIS DISEASE AND ALSO TEACH OTHERS ON IT.
MY PROBLEM HERE IS THAT WE ALL KNOW THAT THIS IS PASSED THROUGH OUR GENETIC SYSTEM AND THAT SADLY WE ARE GIVING IT TO OUR UNBORN CHILDREN WHEN WE DO GET PREGNANT. THE THING IS THAT THEY HAVE THE GENETICS OF OUR PARTNER ALSO AND THEY HAVE A FIGHTING CHANCE WITH SCIENCE THAT IS NOW TAKING INTEREST IN IT,
AS FAR AS BREAST FEEDING, IT HAS BEEN SAID OVER AND OVER THAT WE SHOULD NOT BREAST FEED OUR CHILDREN FOR IT IS IN THE BREAST MILK AND ALSO WE SHOULD NOT GIVE BLOOD TO OTHERS, IE.. BLOOD DONOR. SO IF WE CAN'T DO THAT ,WHY MAKE OTHER WOMAN FEEL GUILTY AND LESS OF A WOMAN FOR NOT BREAST FEEDING. IT IS HARD ENOUGH BEING A PARENT AND SOCIETY MAKES IT HARDER WITH THESE GROUPS PUSHING THE BREAST FEEDING ON PARENTS THAT ARE TIRED, ILL AND SHOULD NOT BE GIVING SOMETHING THAT IS NOT GOOD TO THEIR CHILDREN. CARANATION MILK IS BETTER THAN WHAT YOU ARE PUSHING.
THANKS FOR THE GREAT ARTICLE AND I HOPE THAT OTHER WOMAN WILL NOT FEEL GUILTY IF THEY CAN'T BREAST FEED. IT IS NOT THE WORSE THING. LET ME TELL YOU, PARENTING IS MORE THAN THAT!!!
THE INFORMATION ON FMS WAS FORGOTTEN HERE AND THE ATTENTION WAS FOCUSED ON BREAST FEEDING.. AGAIN.
DIAMOND